Evidence Emerges on Neonatal Abstinence Syndrome

Two years ago, neonatology researchers from Ohio’s children’s hospitals had a game-changing insight into neonatal abstinence syndrome (NAS) – the emerging epidemic of infants exposed to opioids in utero. In comparing NAS treatment protocols across six hospitals, they found significant differences in outcomes, publishing their findings in the journal Pediatrics.

Moira Crowley, MD

“Although we all had protocols, the children’s hospitals that had a shorter length of stay had a very strict weaning protocol for weaning their babies off the drugs,” says Moira Crowley, MD, Director, Fetal Consultative Service, Co-Director, Neonatal ECMO Program, and Neonatologist, UH Rainbow Babies & Children’s Hospital and Assistant Professor of Pediatrics, Case Western Reserve University School of Medicine and one of the study’s authors. “It was really being adherent to the protocol and making people accountable for weaning every day, if the baby allows us to do that.”

In reaction to these findings, the researchers, part of Ohio Children’s Hospital Neonatal Abstinence Syndrome Consortium (OCHNAS), developed a potentially better protocol, designed to humanely and safely wean infants off opioids over a two- to threeweek period. They implemented it across all six Ohio children’s hospitals, and now the results are in: Children’s hospitals that adopted the strict weaning protocol decreased duration of opioid treatment from 34 days to 23 days, and decreased inpatient hospital stay from about 32 days to about 24. These results, too, were recently published in the journal Pediatrics. Michele Walsh, MD, MS Epi, Interim Chair of Pediatrics and Division Chief of Neonatology at UH Rainbow Babies & Children’s Hospital, designed the study.

“Two years ago, there was no strong evidence-based treatment for NAS and thus no consensus regarding NAS management,” Dr. Crowley says. “There is still no national consensus on how to treat these babies. However, there is emerging evidence from our work in Ohio.”

Dr. Crowley and her colleagues statewide are working with the Ohio Perinatal Quality Collaborative to spread adoption of the Ohio protocol. It is based on scoring all infants with NAS according to a modified Finnegan scoring system.

“Once they hit a certain score, you start treatment,” Dr. Crowley says. “Once they’re on a steady dose for 48 hours and the infant’s symptoms are controlled, then you start weaning by 10 percent of that highest dose. It should be a 10-day wean. Then we watch the baby for two days off therapy and discharge the baby from the hospital. Any opioid exposure, whether in utero or ex utero, can cause abnormal neurologic development, so limiting the exposure is what we all want to do.”

They’re also promoting the importance of nonpharmacologic measures in the protocol as essential to success.

“Swaddling, low stimulation, encouraging breastfeeding if appropriate and potentially using low-lactose formula or highercalorie formula can all be helpful,” Dr. Crowley says.

The problem of NAS remains enormous, cutting across all demographic groups and health care settings, from community hospitals to teaching hospitals to children’s hospitals. Plus, for some of these NAS infants, the treatment can be quite complex.

“Many of these babies have polysubstance exposure,” Dr. Crowley says. “For the substances other than opiates, the withdrawal symptoms may be very similar to opiate withdrawal. By using morphine or methadone, we may not be effectively treating withdrawal from these other substances.”

Despite these challenges, however, Dr. Crowley and her colleagues are continuing to ask the questions necessary to arrive at the most humane and effective NAS protocol.

“Can we decrease the length of treatment any more?” she asks. “Can we decrease the dose? There’s been a lot of work done with the methadone part of the protocol. As we learn more about the pharmacokinetics of that drug in neonates, we may be able to decrease the length of treatment even further. But there are still safety issues to address. The best scenario is that physicians become more aware of what medications women are being prescribed while pregnant.”

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